Health experts dismiss Ruto's address as detached from reality

Stakeholders in the health sector have dismissed President William Ruto’s State of the Nation address, terming it underwhelming and short of facts.

They poked holes in the rollout of Universal Health Coverage (UHC), citing a myriad of challenges, including pending debts and low premiums payment rates to the Social Health Authority.

In his speech, Ruto asserted that all Kenyans can now access quality healthcare regardless of their financial status.

Ruto attributed access to care (Universal Health Coverage) to adoption of health reforms and innovations that are taking shape, in addition to the adoption of the Social Health Authority (SHA).

“Over the last three years, we have undertaken the most ambitious transformation of health systems since independence, reforms rooted in equity, powered by innovation, and guided by the conviction that every Kenyan, wherever they live and whatever their means, deserves quality healthcare,” said Ruto.

But Ruto’s declaration comes amid growing concerns that most  Kenyans continue to struggle to access healthcare, especially after repealing of the National Health Insurance Fund (NHIF).

For example, outpatients services under SHA are limited, with the majority of Kenyans paying out of pocket.

Health economist and public policy expert Beatrice Kairu said UHC is far from being realised.

Inadequate funding

Speaking to The Standard shortly after the President’s address, Kairu said access to primary healthcare remains a major challenge, citing an instance where  Public Health Principal Secretary Mary Muthoni has repeatedly cited inadequate funding for the Primary Healthcare Fund and the Emergency, Chronic and Critical Illness Fund.

“When you tell Kenyans to go to health facilities for treatment, yet there is no funding and no drugs, are you being realistic?” posed Kairu.

Clinical officers also poked holes in the government’s claim that UHC is taking shape, arguing that the picture painted by President Ruto does not reflect the realities on the ground.

According to Kenya Union of Clinical Officers Secretary General George Gibore, the performance of UHC cannot be rated from the comfort of a boardroom.

He said those implementing services in the field are struggling with numerous challenges, many of which stem from the funding and structural design of SHA that was meant to drive UHC.

“There is a lot of feedback from the ground that should inform government restructuring of the system. ,” Gibore said.

On Wednesday, Council of Governors (CoG) raised concerns over the roll out of the UHC,and threatened to pull out of the plan.

Chairman Ahmed Abdulahi noted that SHA owed county hospitals more than Sh10.5 billion which had affected payment of debts.

He said that rejected claims for both private and public hospitals was worsened by lack of an appeal mechanism.

“Prolonged delay in releasing the debts has affected the limit to pay suppliers and we are concerned by an increase in rejected claims,” he said.

Reversing gains

Governors insist that there are indications that the Ministry of Health was reversing gains made in strengthening the health docket.

In his speech, President Ruto also highlighted the high registration of SHA members, noting that at least 27 million Kenyans have registered, figures he said were never achieved under NHIF.

He added that more than 10,000 health facilities have agreed to serve under the new system.

While Ruto highlighted the rising number of people registered under SHA, now surpassing that of NHIF, Gibore said “registration figures do not equal compliance or access”.

Gibore added that the indicators that truly define UHC have not improved, especially staffing in health facilities.

“We appreciate that salaries have been harmonised under the Salaries and Remuneration Commission Act. However, staffing numbers have not changed,” he said.

He reminded the government of its initial promise to hire 100,000 health workers in the first year of the UHC rollout.

The pledge remains unfulfilled, leading to over-stretched personnel.

“Some health workers, burned out by workload, have opted to return to school.

‘‘They also promised a central human resource system. This has not happened,”Gibore said.

Kairu said SHA registration numbers alone do not reflect actual functionality, faulting the government of failing to address the critical question of premium remittances.

Sources at SHA told The Standard that only about five million Kenyans are remitting their annual premiums, most of them salaried workers.

Contributions from the informal sector remain low, threatening the sustainability of the scheme.

“You can register everyone, but if Kenyans are not contributing, you cannot say UHC is working. Registration alone does not translate into access to healthcare.”

A senior SHA official revealed that the Authority is collecting about Sh6.7 billion monthly, roughly Sh80 billion annually, but spending about Sh8.7 billion a month, or Sh104.4 billion annually.

“We are basically spending more than we are collecting,” the official said. He added, “When the loss ratio gets too high there is a problem. It means you are encouraging bills you are unable to settle.”

In an earlier interview, the Rural Private Hospitals Association of Kenya (Rupha) warned that unless collections improve, SHA could collapse.

“We now have experience with SHA. Is it working? Kenyans are told to register and get free services. It sounds good but if things continue as they are, SHA could collapse,” said Rupha chairperson, Dr Brian Lishenga.

She added that although the government claims chronic and primary care services are available, patients must first be registered as beneficiaries of the Social Health Insurance Fund (SHIF).

The challenge, she said, is that most Kenyans cannot afford annual SHA premiums capped at 2.75 percent of their earning.

“Out of pocket expenditure is still too high. For example, the President contributed Sh2 million towards gospel musician Betty Bayo’s medical bill at a public hospital. Do we then say SHA is working? If the President himself steps in to clear bills, why are Kenyans still paying from their pockets?” posed the expert.

Kairu dismissed UHC as “a mirage” under the current system.

Even as the President praised SHA, concerns are mounting that the scheme is on the verge of collapse due to low revenue collection and a staggering debt estimated at Sh76 billion owed to public, private, and faith-based facilities.

The debts include Sh33 billion in unpaid NHIF claims and Sh43 billion in pending SHA claims. However, in his address, the President ignored the matter.

Early last month, the Ministry of Health wrote to the National Treasury requesting Sh5.4 billion in the Supplementary Budget to settle pending NHIF debts.

The request was made during a consultative meeting between the Ministry, private healthcare providers, SHA, the Digital Health Agency (DHA), and regulators to review the rollout of Taifa Care.

In the letter, the Ministry admitted that unpaid claims continue to constrain service delivery nationwide, particularly in primary and secondary health facilities.

Additionally, early this week, the Council of Governors (CoG) also raised concern with remittance of SHA debts totalling Sh10 billion.

The unremitted dues according to governors has affected the ability of counties to pay suppliers and have contributed to increasing claim rejections.

Hospitals, experts and officials fear that SHA barely a year old may be headed for a short lifespan as it struggles to stay afloat.

Insiders at SHA warn that the scheme is spending far more than it is collecting, a trend that could cripple the country’s flagship health financing model.

A senior SHA official revealed that the authority is collecting about Sh6.7 billion monthly, roughly Sh80 billion annually, but spending approximately Sh8.7 billion a month, or Sh104.4 billion annually.

“We are basically spending more than we are collecting,” the official said.

He added, “When the loss ratio gets too high for a section of the population, it becomes a problem. It means you are encouraging bills you are unable to settle.”

In an earlier interview, the Rural Private Hospitals Association of Kenya (RUPHA) warned that unless collections improve, SHA could collapse.

“SHA as a pillar. We now have experience with it. Is it working? Kenyans are told to register and get free services. It sounds good and might win elections, but if things continue as they are, SHA could collapse in three to four months,” said RUPHA chairperson Dr Brian Lishenga.

Under the Kenya Kwanza health agenda, the government committed to buying insurance cover for vulnerable groups, including people in prisons.

However, registration of vulnerable households has yet to begin, and no funds have been allocated for their premiums.

Again, during his address, President Ruto praised Community Health Promoters (CHPs), saying they now screen and diagnose diseases such as hypertension and diabetes.

He said their role embodies the spirit of equity and UHC, noting that 107,000 CHPs were deployed in September 2023, the largest primary healthcare workforce in Kenya’s history.

“Behind these numbers, he said, are “quiet, devoted, tireless heroes of this new era,” said Ruto. 

Contrary, payment of Sh2,500 to CHPs by counties remain irregular, with some having gone for months without pay. Each CHP is paid Sh5,000, shared role between county and national governments.

The President further stated that SHA is paying premiums for vulnerable Kenyans, including widows, orphans, the elderly, and those without income.

He noted that at least 2.3 million vulnerable people have had their premiums, paid, though the government has neither registered these groups at community level nor allocated a budget for their pay. 

He also highlighted the plan to modernise hospital equipment through the National Equipment Service Programme (NESP), replacing the controversial MES model, and to increase KEMSA drug refill rates from 46 percent to 90 percent by December.

President Ruto however did not address the long-standing issue of drug shortages in public facilities. 

Nevertheless, a notable gain in his address was improvement of the cancer benefit package from Sh500,000 to Sh800,000 effective December 1.

Stakeholders note that the President should have addressed the high cost of drugs, saying local manufacturing remains constrained by regulatory barriers, and health workers issue.

“Cost of drugs and medication is still high. Regulations and policies that prevent manufacturers from setting up plants must be removed. Otherwise, the cost of healthcare will remain out of reach,” said Kairu.